Minnesota Joint Underwriting Association 12400 Portland Ave S, Suite 190 Burnsville, MN 55337 18005520013 or 9526410260 Fax: 9526410274 www.mjua.org APPLICATION FOR ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY INSURANCE THIS IS AN APPLICATION FOR CLAIMSMADE INSURANCE. 1. Name and Address for firm: County: Email: Phone: Agent Name and Address: Phone: Email: 2. Firm is a: corporation partnership professional corporation sole proprietorship other 3. Number of professional staff, including principals, partners, architects, engineers, inspectors, surveyors, draftsmen, etc: 4. Is this firm or any subsidiary or parent organization engaged in: Yes No construction, fabrication or erection real estate development construction management the manufacture, sale or distribution of any product or process design/build Please explain any yes answers on a separate sheet of paper. 5. Does the firm control or own, or is it controlled or owned by any other firm, corporation or company? yes no Please explain yes answer. 1
6. Does the firm require certificates of professional liability insurance form all its Consultants? yes no 7. What were your firm s total billings for professional services, including all fees paid to consultants, and the total construction values of all projects during the past 12 months? Total billings Total construction values 8. Indicate the percentage of total billings above derived from professional service contracts soley for feasibility studies, master planning, interior design, reports, opinions, or environmental impact studies. % 9. Please indicate which of the following disciplines are performed by your firm by showing the percentage of billings for each for the past 12 months. (Excluding services performed by consultants.) Architecture Civil Engineering Land Surveying Construction Management Other (please specify) Landscape Architecture Soils Engineering Structural Engineering Mechanical Engineering Electrical Engineering 10. Please indicate the percentage of work performed under the following categories: Foundation Design Mining Engineering Inspection/Observation of construction where involved in design Site Evaluation PROJECTS Marine Engineering Oil/Gas Well Engineering Inspection/Observation of construction where NOT involved in design Project certification for benefit of any party other than applicant s client Airports Hospitals Utilities Manufacturing or industrial bldgs Office buildings Pipe Lines Petrochemical facilities Sewage Treatment facilities 2 Chemical Plants Harbors, piers, ports Water systems Material handling/storage system Nuclear/Atomic projects Sewage Systems Shopping Centers Sports and Convention Centers
Subdivision/Tract Developments Religious, charitable or other organizations 3
11. Please indicate the percentage of services rendered for each of the following categories. Base responses on the percentage of applicants gross volume derived from each category: Commercial/Industrial Federal Government Local Government State Government Other (specify below) Contractors Design professional Real Estate Developer Owners acting as own builder 12. Please indicate the percentage of services rendered for the following categories: *ski lifts, commercial amusement rides or skateboard parks surveys for subsurface conditions *work performed for communist block countries *work performed outside the US, its territories or Canada, other than communist block countries * For these categories, provide complete description including client, location, construction value, services rendered, and present status. 13. Does the applicant s practice involve any subcontracting of services to others? Yes No If yes, specify services and percentage of overall volume. 14. Are more than 50% of the billings for the past or the next 12 months to be derived from a single client or contract? Yes No If yes, specify client or contract and describe all services to be rendered. 15. Please specify percentage, if any, of billings for the next 12 months expected to be derived from : A. services for owners of projects who act as their own contractor B. services for package, design/build or turnkey projects If the total of A and B is larger than 50%, please provide full details. 16. Please indicate all professional societies in which you are a member: 4
17. If nonstandard or modified AIA/NSPE/PEPP contracts are used, are they reviewed by you legal counsel for liability implications prior to signing? Yes No 18. Does the firm ever enter into contracts which contain indemnification or hold harmless agreements? Yes No 19. Does the applicant have inhouse quality control procedures, and if so, are they in written form? Yes No 20. Does the firm have an inhouse program of continuing education for employees? This would include attendance at AIA/NSPE/PEPP sponsored seminars and similar functions. Yes No 21. Please specify the percentage of the firm s: Professional services rendered under AIA or NSPE/PEPP standard forms of agreement between owner and architect or engineer Projects ultimately constructed under AIA or NSPE/PEPP standard general conditions of the construction contract Projects incorporating specifications based on or derived from the automated master specifications system known as Masterspec Construction management services, rendered under the unaltered American Institute of Architects B801 Standard form of agreement _ THE FOLLOWING QUESTIONS APPLY ONLY TO NEW APPLICANTS. 22. Has the name of the firm ever changed or has there ever been an acquisition, consolidation, dissolution, merger or change in business organization? Yes No If yes, provide full particulars listing each firm named in chronological order and specify the date, name or business organization changed. 23. Have any claims, suits or demands for arbitration been made against the firm, its predecessors or any past or present principal, partner, officer or director? Yes No If yes, on a separate sheet give complete details. 24. Have any of the principals, partners, officers, employees or directors or any predecessors knowledge of any error, omission, unresolved job dispute (including ownercontractor disputes) accident or any other circumstance that is or could be a basis for a claim under the proposed insurance? Yes No If yes, on a separate sheet of paper give complete details. 5
25. Has any insurer declines, canceled or refused to renew any similar insurance issued to the firm or any of the persons named in question 23? Yes No If yes, give details. 26. Describe nature of operation. Please attach brochure describing firm. 27. Give full name and professional qualifications of all principals, partners or officers of current firms and dates of employment. (Registrations and degrees, date and place required.) If previously a principal, partner of officer of another firm, indicate firm name and employment dates. 28. On a separate sheet, list your five largest current projects. Please give name of project, location, description, owner, nature of services rendered, and status. (Completed, under construction, proposed, etc.) Also, provide the above information for your 10 largest projects over the last 5 previous years. PRIOR CARRIER INFORMATION Limits Annual Year Carrier Policy No. BI/PD Premium The following questions must be answered by all applicants. Does the applicant conduct any activities outside the state of Minnesota for which the applicant is applying for insurance from MJUA? If Yes, identify the percentage amount of the applicant's activities conducted outside the state of Minnesota; the states in which those activities are conducted; and describe such activities. Is the insurance for which the applicant is applying for from MJUA required by statute, ordinance, or otherwise required by Minnesota law? If Yes, identify the statute, ordinance, or Minnesota law requiring such insurance. 6
THE FOLLOWING QUESTIONS MUST BE ANSWERED BY ALL APPLICANTS. ( Yes answers do not require explanation) Does the applicant understand that the insurance being applied for does not cover, and will not indemnify, the applicant for any liability or loss arising from the applicant's activities that are conducted substantially outside the state of Minnesota, unless required by statute, ordinance, or otherwise required by Minnesota law. I, the undersigned, certify and attest on behalf of the applicant that I have been unable to obtain through ordinary methods, the insurance I am applying for with this application and the information contained in this application is true and complete. Please identify the name of the insurance company who has refused to provide coverage to the applicant and the date of the refusal. Was the refusal to provide coverage by another insurer based on an offer of coverage at a rate in excess of the rate that would be charged by the MJUA for similar coverage and risk? If Yes, and the rate for coverage offered is more than 10% in excess of the MJUA's rates for similar coverage and risk, or 20% in excess of the MJUA's rates for liquor liability coverages, attach a copy of such written offer to this application. NOTE that pursuant to Minn. Stat. 62I.13, Subd. 2, "[i]t shall not be deemed to be a written notice of refusal if the rate for coverage offered is less than ten percent in excess of the joint underwriting association rates for similar coverage and risk or 20 percent in excess of the Joint Underwriting Association rates for liquor liability coverages." If No, provide further explanation. Does the applicant understand that the insurance being applied for does not cover and will not indemnify the applicant for any liability or loss arising from the emission of any hazardous material or pollutant to the environment, including any responsibility to clean up any release; and does not cover and will not indemnify to application for liability or loss arising out of products made or completed operations performed by the applicant or on the applicant s behalf, including materials, parts, or equipment furnished in connection with such products or operations. Yes No 7
I, the undersigned, certify and attest that I have been unable to obtain through ordinary methods, the insurance for which I am applying for with this application and the information contained in this application is true and complete. Yes No APPLICATION REQUIREMENT AS PART OF YOUR APPLICATION, YOU ARE REQUIRED TO SUBMIT ONE REJECTION OF COVERAGE FROM A STANDARD INSURANCE CARRIER. A WRITTEN QUOTE PROVIDED BY AN INSURER AT A RATE IN EXCESS OF 110% OF PLAN RATES FOR SIMILAR COVERAGE IS DEEMED TO BE A WRITTEN REJECTION. Signature: Date: 8